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ATRIO Prime Rx (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for ATRIO Prime Rx (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on ATRIO Prime Rx (PPO) in 2025, please refer to our full plan details page.
ATRIO Prime Rx (PPO) is a PPO plan offered by ATRIO Health Plans available for enrollment in 2025 to people living in Douglas County. This plan received an overall rating of 3 out of 5 stars in 2025.
It's important to know that ATRIO Prime Rx (PPO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about ATRIO Prime Rx (PPO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For ATRIO Prime Rx (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $96.00. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $20.00. You must continue to pay paying your reduced Part B Premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $6200.00 (in-network or out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $6200.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
The plan may have separate out-pocket-maximums for in-network and out-of-network services. See our full plan details page for more information.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The ATRIO Prime Rx (PPO) plan has a $0 deductible for prescription drugs. In the initial coverage phase, you'll pay a copay for your prescriptions based on the drug tier and pharmacy type. For example, you'll pay $8.00 for preferred generic drugs at a standard pharmacy, and $47.00 for standard generic drugs. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase, where you pay nothing for covered drugs. If you qualify for the low-income subsidy (LIS), your monthly premium is $18.90.
Additional Benefits
The ATRIO Prime Rx (PPO) plan provides a wide range of benefits, including inpatient hospital stays with a copay, outpatient services, and emergency services. This plan also covers primary care services with varying copays, preventive services, and specialized services like hearing, vision, and dental. Additional benefits include ambulance and transportation services, along with home health services. This plan offers coverage for diagnostic and radiological services, medical equipment, and skilled nursing facility stays with specific copays. The plan also offers additional services like acupuncture and over-the-counter items. However, it's important to note that certain services, such as podiatry services, are not covered.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For Inpatient Hospital-Acute, you'll pay a $350 copay for days 1-8, and no copay for days 9-90; for Inpatient Hospital Psychiatric, you'll pay a $350 copay for days 1-6, and no copay for days 7-90. Additional Days for Inpatient Hospital Psychiatric, Non-Medicare-covered Stay for Inpatient Hospital Psychiatric and Upgrades for Inpatient Hospital-Acute are not covered.
Outpatient Services See details
Outpatient Services include coverage for Outpatient Hospital Services and Observation Services, each with a $275 copay, Ambulatory Surgical Center (ASC) Services with a $225 copay, and Outpatient Substance Abuse Services with a copay between $35 and $35 for individual and group sessions. This plan also covers Outpatient Blood Services.
Partial Hospitalization See details
Partial Hospitalization is covered under the ATRIO Prime Rx (PPO) plan, with a copay of $55.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, with a $225 copay for both ground and air ambulance services, and no coinsurance. Transportation Services to any health-related location are covered for up to 12 one-way trips per year, and other transportation services are not covered.
Emergency Services See details
Emergency Services are covered by the ATRIO Prime Rx (PPO) plan with a $140 copay and no coinsurance. Urgently Needed Services have a $65 copay and no coinsurance. Worldwide Emergency Services are covered, with a $140 copay for Worldwide Emergency Coverage and Worldwide Urgent Coverage, while Worldwide Emergency Transportation is not covered.
Primary Care See details
The ATRIO Prime Rx (PPO) plan covers primary care physician services, chiropractic services with a $20 copay, occupational therapy services with a $30 copay, physician specialist services with a $35 copay, and mental health specialty services. The plan also covers other health care professional services and psychiatric services. Additionally, the plan covers physical therapy and speech-language pathology services with a $30 copay, additional telehealth benefits with a copay between $0 and $35, and opioid treatment program services with a $35 copay. Podiatry services are not covered.
Preventive Services See details
Preventive Services are covered, including Medicare-covered preventive services, annual physical exams, and additional preventive services. The plan covers Personal Emergency Response Systems, Alternative Therapies, and Fitness Benefits with a maximum plan benefit coverage amount.
Hearing Services See details
Hearing Services include coverage for hearing exams with a $35 copay, fitting/evaluation for hearing aids, and prescription hearing aids up to $1500 per year. Prescription hearing aids do not cover inner ear, outer ear, or over the ear hearing aids. OTC hearing aids are not covered.
Vision Services See details
Vision services include eye exams with a $15 copay, and eyewear, including contact lenses and eyeglasses. The plan covers one routine eye exam and one pair of contact lenses or eyeglasses per year, with a combined maximum benefit of $200 per year for eyewear. Eyeglass lenses and frames are not covered.
Dental Services See details
Dental services are covered by ATRIO Prime Rx (PPO), including a $35 copay for Medicare dental services. Other dental services have a maximum benefit of $350 every three months.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered under the ATRIO Prime Rx (PPO) plan. Medicare Part B Insulin Drugs have a $35 copay and a coinsurance between 0% and 20%, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the ATRIO Prime Rx (PPO) plan with a coinsurance of 20%.
Medical Equipment See details
Medical Equipment coverage includes Durable Medical Equipment (DME) with 0% to 20% coinsurance, Prosthetic Devices with 20% coinsurance, and Medical Supplies with 0% to 20% coinsurance, but does not cover Durable Medical Equipment for use outside the home, Diabetic Supplies, or Diabetic Therapeutic Shoes/Inserts. There is no copay for these services.
Diagnostic and Radiological Services See details
The ATRIO Prime Rx (PPO) plan covers diagnostic and radiological services, but lab services are not covered. Diagnostic Procedures/Tests have a minimum copay of $0 and a maximum copay of $15, while Diagnostic Radiological Services have a maximum copay of $100, Therapeutic Radiological Services have a $60 copay, and Outpatient X-Ray Services have a $15 copay.
Home Health Services See details
Home Health Services are covered by the ATRIO Prime Rx (PPO) plan with no copay and no coinsurance. However, additional hours of care and personal care services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by ATRIO Prime Rx (PPO), but all Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are not covered. Prior authorization is required for this benefit.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the ATRIO Prime Rx (PPO) plan. For days 1-20, the copay is $20, and for days 21-100, the copay is $175, while additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
The ATRIO Prime Rx (PPO) plan covers acupuncture with a maximum benefit coverage amount of $300 every six months, and also covers over-the-counter items up to $75 every three months. Additionally, the plan offers a meal benefit requiring prior authorization and other services including AWV once per calendar year. The plan does not cover Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services.
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Every year, Medicare evaluates plans based on a 5-star rating system.
Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
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